Hostwork International - Secure Order Form

S E C U R E O R D E R F O R M
Data sent with this form is encrypted using SSL

1. Specify new or existing domain name:

Domain: www. E.g. Abc-123.com Only use letters A to Z, numbers 0 to 9 and - (hyphen)
New domain registration: Make sure this is what you want as it cannot be changed once registered.

	I want Hostwork to handle the registration on my behalf (through eNom.com)	We'll register the domain name for you at our discounted rate of $20.00/year. (.com .net and .org only)
	I'll handle the registration myself	You'll need our DNS information.
	I've already registered this name and want Hostwork to handle the transfer	We'll submit the modification request for you. An e-mail confirmation and/or password may be required from you.
	I'll handle the transfer myself	You'll need our DNS information.

2. Select an account and any option needed: (all options can be added later)

Advanced Web Site (select this if you have a webmaster to manage your site) $25.00/month + last month deposit Managed Web Site (select this if you want us to manage your site for you) $75.00/mo.+ one time setup fee of $150.00	Options	Monthly
	Advanced Stats	Free
	Web-based Email	Free
	MySQL Database	Free
	Web/FTP Stats	Free
	FrontPage2002	$2.00
	Majordomo	$5.00
	Miva Merchant	$15.00
	Anonymous Email	$25.00

3. Select inital payment:

1 month

2 months

3 months

6 months (+1 mo. free)

1 year (+2 mo. free)

4. Enter your contact/billing information:

We respect your privacy. This information will not be shared with anyone, except the registrar if we are registering a domain name for you. If you would like us to provide different infomation to the registrar, specify it in the comments area.
Name:
Company:	optional
Address:
City:	State: Zip:
Country:
Phone:	Fax: optional
Email:

5. Select method of payment:

Check (U.S. banks only)

Cash (At your own risks! Always send registered or certified)

Money Order (U.S. Post Office or International USD)

PayPal (Payment link on next page)

Credit Card:
Card Number:	Expiration Date: /
CVV2:	What is CVV2?
Select:
Credit Card Statement Billing Address same as contact information
Name on Card:
Address:
City:	State: Zip:
Country:

6. Describe the intended use for your site and any comment:

7. Tell us how you found Hostwork:

Name, location or ref. #

8. Read the Service Agreement. Click here to open our service agreement in a new window.

I have read and agree with the terms of service.

9. Verify your data and submit.